Suicidology Online 2010; 1:34-52. ISSN 2078-5488

Essay Cultural Research in Suicidology: Challenges and Opportunities

Heidi Hjelmeland

Norwegian University of Science and Technology, Trondheim Norwegian Institute of , Oslo, Norway

Submitted to SOL: 31th July 2010; published: 17th August 2010

Abstract: Cultural research in suicidology is crucial in order to develop our understanding of the meanings of suicidal behaviour in different cultural contexts. In this essay, I will first elaborate why it is important to focus on cultural issues in suicidological research and thereafter discuss what it actually means to have a cultural focus/perspective on the research. Then I discuss some of the challenges, as well as opportunities, faced in cultural suicidological research. The main focus is, however, on challenges and these are conceptual, theoretical, methodological, ethical and political in nature. In the literature we meet a confusing mix of concepts, for instance, transcultural, cross-cultural, inter-cultural or simply just cultural. Each of these concepts has numerous different definitions; sometimes used interchangeably, other times carrying different meanings. A central question is also: What is culture? An important methodological question is: Is culture a measurable variable? My answer to this question is no, and then the next important question is: How can we then study (trans/cross/inter)cultural aspects of suicidal behaviour? Here I will propose using qualitative methodology in order to be able to analyse the cultural contributions to suicidal behaviour. The need for theoretical frameworks is also discussed. Examples of ethical and political challenges are, among others, negative attitudes towards cultural research and qualitative methodology, the increased focus on biological research, as well as some challenges faced when researchers from different cultural contexts collaborate. Although cultural suicidological research in general is emphasised throughout, I also discuss challenges particularly relevant for research in low and middle income countries and/or among minority groups in high income countries.

Copyrights belong to the Author(s). Suicidology Online (SOL) is a peer-reviewed open-access journal published under the Creative Commons License 3.0.

*Suicidal behaviour always occurs and is focus/perspective on the research. Thereafter I discuss embedded within a cultural context and no suicidal some of the challenges as well as some opportunities act is conducted without reference to the prevailing faced when we include a cultural perspective in our normative standards and attitudes of a cultural research. Although the value, importance, challenges community (Salander Renberg & Jacobsson, 2003; and opportunities of cultural perspectives in general Stillion & Stillion, 1998-99). This is reflected in the are emphasised throughout, I also discuss challenges variations in rates and risk factors of suicidal particularly relevant for research in low and middle behaviour across countries (Salander Renberg & income countries and/or among minority groups in Jacobsson, 2003; Vijayakumar et al., 2005). Hence, high income countries. it is imperative to take cultural issues into consideration in all kinds of suicidological research. Why it is Important to have a Cultural Perspective However, in doing so, we face a number of on Suicidological Research challenges. These are, for instance, conceptual, theoretical, methodological, ethical and political in “People eat, drink and breathe culture” (Bhugra nature. In this essay, I will first elaborate why it is so & Bhui, 2007, p. xvii). In other words, culture is the important to focus on cultural issues in fundament of peoples’ lives and hence will be of suicidological research followed by a discussion of crucial importance to their suicidality as well. Tseng what it actually means to have a cultural (2007) has emphasised that “…culture has a significant pathofacilitating effect on suicidal behaviour” (p. 106), by that that cultural * Heidi Hjelmeland Department of and Health Science factors contribute significantly to the occurrence of Norwegian University of Science and Technology suicidal behaviour in a society. Prevalence and risk NO-7491 Trondheim factors for suicidal behaviour do clearly vary across Norway regions, countries and parts of the world (e.g., Tel: +47 73 59 18 83 Fax: +47 73 59 18 85 Vijayakumar et al., 2005a and 2005b) implying that E-mail: [email protected] culture may play an important role in suicidal

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Suicidology Online 2010; 1:34-52. ISSN 2078-5488 behaviour. Chen et al. (2007) maintain that studies phenomenon under study. However, in traditional of mechanisms responsible for cultural differences cross-cultural studies it is difficult to “…decide which have an important heuristic function for advancing variables represent ‘culture’ and should therefore not our understanding of individual variation, since the be controlled, and which variables do not, and should mechanisms responsible for cultural differences be controlled…” (Medin et al., 2007, p. 620). This is a “often are similar or identical to those determining methodological challenge that will be further dealt individual variation” (Chen et al., 2007, p. 73). with below. Moreover, “’Cross-cultural’ Thus, studies in or from different cultural contexts ….must always first be ‘cultural can teach us something about suicidal phenomena psychology’ in order for it to be meaningful. Cultural (i.e., , non-fatal and fatal suicidal psychology seeks to understand how behaviour is behaviour) as such; they will enhance our influenced by the social context in which it occurs” understanding of what suicidal behaviour means in (Mac Lachland and McGee, 2007, p. 44). different cultural contexts. This is important in order “Psychology” can easily be replaced with to develop the suicidological field itself, as well as “suicidology” here. That is, within-culture variations to enable us to develop culture sensitive knowledge can illuminate how different cultural institutions bases for prevention. Also, by looking at shape thinking or behaviour and vice versa (Medin et suicidal behaviour in or from a different culture than al., 2007). In other words, to have a cultural our own, we can see this behaviour in our own perspective on one’s research basically means to take culture in a new light and hence get a better the sociocultural context into consideration in the understanding of what this behaviour is all about and analyses and not just study the individual/group thus how it best can be prevented (Hjelmeland & stripped of the context. Knizek, in press). Moreover, no matter how we Thus, to have a cultural perspective on one’s define culture (definitions will be dealt with below) research can mean both to study something within one it is safe to say that all countries are multicultural cultural context and to compare something across one way or the other and that currently “…within different cultural contexts. The main point, however, any specific regions, the populations are rapidly is that one is conscious/explicit about having this becoming diversified” (Yu et al., 2007, p. 403). perspective, that is, one is explicitly taking the Thus, even if one is not particularly interested in sociocultural context into consideration in the what goes on elsewhere in the world, we need to analysis. Otherwise, all the numerous risk factor take cultural aspects of suicidal behaviour into studies conducted in Western countries could be consideration in our own multicultural societies. In labelled cultural, when surely they are not since the Medin et al.’s (2007) statement that ”…psychology cultural context is most often not explicitly taken into needs cultural research to be legitimate” (p. 615), consideration in the analyses. Likewise, conducting “psychology” can easily be replaced by studies in, for example, an African country, does not “suicidology”. automatically make it cultural, unless the researchers are analysing their data in relation to cultural factors. What does it mean to have a Cultural Perspective In this essay, cultural research in both meanings, that in Research? is, within as well as between cultural contexts is addressed and challenges faced in conducting such Sometimes it seems like some journal research are discussed. editors, reviewers, and researchers relate a cultural All research takes place within a specific perspective to research taking place “somewhere cultural context regardless of how culture is defined. else”, that is, mainly outside the so-called Western This has, for instance, implications for generalisation part of the world. At least that is the impression one of results. Therefore, it is important to encourage gets when some Western based journal editors reject suicidological research from all over the world and articles, because they contain a cultural perspective, from many different cultural contexts, within as well that is, the study is conducted in, for instance, an as between countries. And, it is perhaps necessary to African country, and therefore the results are increase the consciousness among some Western deemed irrelevant for a Western audience. This is a researchers that their results are not universal because political challenge that will be further dealt with their research is also conducted in a specific cultural below. context, consisting of many cultural contexts Previous suicidological research with a simultaneously. In fact, results may not even be specific cultural focus has mainly been in the form generalisable within the region/country where the of quantitative cross-cultural comparisons, for research is conducted since most societies are instance, studies comparing some aspects of suicidal multicultural which means that the understanding of a behaviour between a Western and a non-Western phenomenon and the prevention strategies developed country, or, between the majority and a minority on, for instance, the majority population in a society, population within a country. When phenomena are might not be applicable to minority groups in that compared across cultural groups you may get an society. Moreover, researchers are themselves part of impression of how cultural factors influence the and embedded within their own cultural contexts; not

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Suicidology Online 2010; 1:34-52. ISSN 2078-5488 only the context constituted of the culture they are is, when differences across countries or regions of the socialised into from birth/childhood, but also, for world are found, they are often described as caused by instance, the one connected to their specific culture. Valsiner (1988) has pointed out that this has professions. We can safely say that there may be a sometimes resulted in a state of perfect tautology in number of (also) cultural differences between, for causal explanations in that a phenomenon “observed instance, the psychiatric and sociological in a sample from a ‘culture’ (here meaning communities in terms of methodological ‘population’) can be caused by ‘culture’” (p. 4). For preferences, choice of study focus and terminology, example, “Italians are found to be ‘Italian’ because among others. they are from Italy” (Valsiner, 2007, p. 25). This does not really make sense, particularly since most, if not Challenges and Opportunities in Cultural all, countries are multicultural depending on how we Suicidological Research define culture (Valsiner, 1988). The question is then: How can we define culture? The main emphasis of this essay is put on More than 150 definitions of culture exist some of the challenges faced in cultural (Ingstad, 2007). “Some define it as shared ‘practices’ suicidological research, but some opportunities are (what people do) and others as ‘shared meanings’” also mentioned where relevant. Although there is (Triandis, 2007, p. 62). According to Lewis some overlap between some of the types of (2002/2004), “Culture … is best understood as the challenges, the following discussion is divided into processes of meaning-making within a given social conceptual, methodological, theoretical, as well as group” (p. 3) and Kitayama et al. (2007) have ethical and political challenges (the last two emphasised that “….culture is both inside and outside discussed under the same heading). the mind” (p. 168). According to Valsiner (2003; 2007), culture has three meanings: 1) People “belong Conceptual Challenges to” a culture. This is the most common meaning of culture where the concept is used to designate a group A confusing mix of concepts is being used of people who “belong together” because they share in the literature, for instance, transcultural, inter- some features. This is the meaning most often cultural, cross-cultural or simply just cultural; each employed in traditional cross-cultural studies, more or of these concepts having a lot of different less consciously, as well as the meaning mostly used definitions, sometimes meaning more or less the by lay people. Culture is here often equalized with same, but sometimes having very different countries or regions of the world, and, seen as a static, meanings. Often without being defined, “cross- independent, causal or explanatory variable; i.e. when cultural” is the concept widely used in comparative differences between countries or regions are found, studies between countries. “Transcultural” is they are explained in terms of cultural differences. 2) sometimes used as equivalent to “cross-cultural” and Culture “belongs to” each individual person. In this sometimes as something different, for instance, meaning, culture is something that is found within the defined as “moving through and beyond cultural intrapsychological systems of each individual person barriers” (Wittkower & Rin, 1965). In a globalised and it is thus irrelevant to which ethnic group or world, “’transcultural’ takes on new meaning based country a person belongs to. 3) Culture “belongs to” on the recognition that cultures are always mixed or the interrelation between the individual and the creolized, giving rise to new forms” (Kirmayer, environment. That is, culture is defined as the process 2007, p. 13). According to Berliner (2001), of interaction between the person and his/her transcultural denominates the new culture growing surroundings; as the dynamics that arise in the out of the process that arises when people from interaction between the person and the environment. different cultures meet, that is, the process of This dynamics cannot be explained in a linear cause- exchange between cultures, constituting an “over- and-effect relationship. Thus, culture cannot be cultural” whole. Some simply prefer “cultural” to treated as a causal or explanatory variable in case include all the above based on the reasoning of differences between countries or regions are found Favazza and Oman (1978): “We prefer to use the (Berliner, 2001; Valsiner, 2007). Culture simply adjective ‘cultural’ rather than ‘cross-cultural’ or cannot be operationalised as a variable to be used in ‘transcultural’ because it is more inclusive, less research projects (Jenkins, 1994). “Culture” is not a exotic, and does not imply a single methodology” (p. measurable variable; it cannot be measured on a scale 293). However, perhaps the biggest conceptual from 1-10 where we can say that some have a lot of challenge is how to define the concept “culture” culture and others have little, or, in terms of presence itself. or absence, where we can say that some have culture, Often, culture is simply taken to be the others do not. If culture is treated as a causal or equivalent to countries or regions of the world explanatory variable in case differences between (Valsiner, 1988). Hence, culture is often viewed in countries or regions are found, it is very easy to an essentialist form as a static entity that has been overlook the real reasons for the differences that may rendered explanatory power (Berliner, 2001). That or may not have anything to do with culture (Berliner,

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2001). According to Berliner, to view culture as a on the other hand, use the same word to describe substantial or essentialist or causal concept, as often anger and sadness (Hansen, 2005); two is the case in traditional cross-cultural studies, erases Norwegians find extremely different. Surely, such real social and/or political life conditions. If we differences between languages have enormous instead of culture talk about, for instance, implications for the translation of, for instance, oppression, marginalization, racism, unemployment, instruments to measure level of depression. and stigmatization, we contextualize peoples’ life Consequently, many authors have pointed out that situation (Berliner, 2001). So, because culture is not albeit the development of diagnostic manuals and a measurable variable, although it is often treated as standardised questionnaires by means of logical such, it is difficult to know what causes what in empiricism have contributed to clearer definitions and traditional quantitative cross-cultural studies (more improved reliability, this has been at the expense of on that under methodological challenges below). validity (e.g., Alarcón et al., 2002; Fulford et al., If culture is not a measurable variable 2007; Kupfer et al., 2002). (Jenkins, 1994) but a process of interaction between Moreover, as mentioned above, differences the person and his/her surroundings (Berliner, 2001; found may have little or nothing to do with culture at Valsiner, 2003; 2007), a relevant question is: How all (Berliner, 2001). In cross-cultural studies we need can we then study the cultural aspects of suicidal to take a number of variables into consideration and behaviour? Below, a few such methodological the problem becomes then to decide which variables challenges, as well as some opportunities, are to control for and which ones not to since it is difficult discussed. to know which variables represent culture (Medin et al., 2007). All this makes quantitative comparisons Methodological Challenges and Opportunities across cultural contexts rather difficult, if not impossible. Another problem is that such research Highly appropriately, Cohen (2007) has most commonly studies the “collective culture” stated that “…very few (or perhaps no) through averaging of the “personal cultures” of the methodological problems become easier when informants and thereby does not take into culture is added to the picture” (p. 196). Medin et al. consideration the fact that there are huge individual (2007) have described studying culture as differences within a cultural group (Valsiner, 2003) “describing a moving target” (p. 637). Furthermore, and that such individual differences may outweigh referring to the conceptual challenges outlined group differences in both extent and importance above, it adds to the problems that “The methods (Fernando, 2002). Furthermore, sampling is a themselves have assumptions built into them about methodological challenge in cross-cultural research. what culture is” (Cohen, 2007, p. 230). True random sampling is basically impossible to get (Valsiner, 2003). Often cross-cultural studies use Problems with mainstream cross-cultural research students based on the rationale that students at least share some features believed to make comparisons Suicidological studies with a cultural focus easier/more valid, for instance, similar age and level have so far most often used a cross-cultural of education. However, students can never be said to approach (etic position) where comparisons have be a representative sample of a country’s or region’s been made across nations or different cultural inhabitants making it impossible to generalise validly groups within a country mainly using quantitative from students to general populations. Valsiner (2003) methodology. This is mainstream psychological, also points out that this kind of research often lacks a psychiatric and hence suicidological research. theoretical foundation. This makes it difficult to However, there are a number of problems inherent interpret results from quantitative cross-cultural in such cross-cultural comparisons. Using the same studies. Thus, an alternative is then to move away (standardised) instruments in different cultural from a cross-cultural to a cultural focus (Cole, 1996); contexts raises problems with reliability and validity the emic perspective. That is, a phenomenon is (e.g., Hjelmeland et al., 2006); we don’t always studied within a culture by native researchers and know what we are comparing. Reliability may, without comparing the findings to other cultures. This relatively speaking, be easy to obtain, but validity is approach has its own challenges that are further a different matter. Diagnostic manuals or discussed below. questionnaires can serve as an example here. Psychological variables are difficult to translate from one language to another and there are huge We need qualitative research variations across different languages in terms of, for instance, nuances in describing various emotions. Seeing as culture is not a static entity, nor an Norwegians, for instance, have a lot of different independent, causal, explanatory or even measurable words for expressing sadness; Hansen (2005) variable, it is now time to add some “new” approaches mentions 14. These are not synonyms but express to studies with a cultural perspective on suicidal different nuances of sadness. The Yoruba in Nigeria, behaviour. That is, we need studies employing

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Suicidology Online 2010; 1:34-52. ISSN 2078-5488 different kinds of qualitative methodology. calls for the application of qualitative methodology in Qualitative studies give us the opportunity to answer cultural studies where a search for meaning is central. the “what”, “how” and “why” questions and such We need methodology that allows us to focus more on questions need to be answered before it gives understanding the meanings of suicidal behaviour in meaning to ask the “how much” questions different cultural contexts rather than on just trying to (Brinkmann, 2009, Hjelmeland & Knizek, in press). explain it in terms of different statistical relationships, Brinkmann (2009) has emphasised that a qualitative for instance, with various risk factors (Hjelmeland & understanding of the psyche is an essential Knizek, in press). The methodology of cultural requirement for psychology itself. The same applies psychology (and hence cultural suicidology) needs to to suicidology; we need to understand what suicidal be systemic, idiographic and qualitative (Valsiner, behaviour means to people in different cultural 2007). Through different kinds of qualitative analysis, contexts before it gives meaning to compare we can interpret, and thus develop an understanding quantitatively across them (Hjelmeland & Knizek, in of how cultural factors contribute to the suicidal press). process (or not). Qualitative approaches are, of course, not at Valsiner (2003; 2007) argues that also all new in research. Already in 1977, analysis of individual cases is valuable here; a Kleinman suggested that an ideal cross-cultural common approach in . He study should begin with phenomenological explains that in studies of individuals we build descriptions that are indigenous to each cultural systemic models of the cultural functioning of the group which simply means that we try to meet individual in his/her social context. This systemic people where they are with the least possible model is in turn tested on another individual, which transference of our own “cultural baggage”, that is, then probably will lead to a modification of the our specific cultural world view. According to model. Then this modified model is again tested on a Fulford and colleagues (2007): “….phenomenology third individual and so on. This is thus a hermeneutic and related disciplines, as rigorous approaches to construction of knowledge about individuals’ analysing experience supported by detailed functioning in their environment, and, “the theoretical frameworks, provide tools for more generalised model becomes ideally applicable to effective and inclusive ways of understanding human beings in their generic state” (Valsiner, 2007, differences not only between individuals but also p. 29). Support for the importance of what individual between cultures in the way they experience the cases can contribute to science was eloquently and world” (p. 39). humorously expressed by the neurologist Vilayanur S. However, for some reason qualitative Ramachandran when he was interviewed by Doidge studies are, even today, met with resistance, even (2007): prejudice, in psychiatric and psychological journals Imagine I were to present a pig to a skeptical in general (Brinkmann, 2009; Marchel & Owens, scientist, insisting it could speak English, then 2007), as well as in suicidological journals particular waved my hand, and the pig spoke English. (Hjelmeland & Knizek, in press). Why we need Would it really make sense for the skeptic to qualitative methodologies and how they can be argue, ‘But that is just one pig, Ramachandran. utilised in suicidological research in general have Show me another, and I might believe you!’” been dealt with at length elsewhere (Hjelmeland & (p. 178) Knizek, 2010; Hjelmeland & Knizek, in press; Leenaars, 2002a; Leenaars, 2002b). Here, the It would perhaps be better to try and find out emphasis is on why they are important in cultural how/why this pig could speak English (or talk at all) suicidological research. In this, we can draw on by studying it and its context in depth. It is through research from, for instance, and qualitative idiographic methodologies the anthropology that are light years ahead of researcher(s) can develop an understanding of an psychology and when it comes to using individual case in detail (Valsiner, 2007); in how this qualitative methods. It is fair to say that suicidology individual interacts with the surroundings and thus to theoretically finds itself at the intersection between, understand the suicidal process. Here, analytical among other disciplines, psychology, psychiatry, generalisation comes to the fore (Kvale, 1997). sociology, and anthropology and should therefore be Through idiographic methodologies one can able to draw on the methodology from all these generalise “on the basis of evidence of individual disciplines. For instance, social anthropology takes systemic cases, and [apply] its generalised knowledge the structure of social organisational forms that to new, and always unique, individual cases” make up society into consideration, something that (Valsiner, 2007, p. 388). In analytical generalisation it is most often missing in cross-cultural psychology is the users of the knowledge who determine whether (Valsiner, 2007). a finding can be applicable in their case/situation by Since culture can be understood as the comparing their case to what is found in another case. processes of meaning-making in social groups The validity of such an analytical generalisation (Lewis, 2002/2004), this in itself warrants and even depends on how relevant the compared characteristics

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Suicidology Online 2010; 1:34-52. ISSN 2078-5488 are, which again depends on detailed, compact, and In the words of Medin et al. (2007): “both rich descriptions of the case (Kvale, 1997). within- and between-culture similarities and The only way to improve our understanding differences are recruited in the service of of suicide in different cultural contexts is to get as understanding how culture affects thought” (pp. 637- much information as possible on which vulnerability 638). factors that are important in individual cases of With the current predominance of suicide in these different cultural contexts quantitative cross-cultural studies we have perhaps (Tousignant & Laliberté, 2007). Thus, in order to started in the wrong end in cultural suicidological understand individuals with suicidal ideation and/or research. It is important to understand the behaviour, we have to understand how these phenomenon we are studying, in this case suicidal individuals perceive their world and themselves in behaviour, in different cultural contexts before it is this world; why it is that they want to “resign” from meaningful to explain it, for instance, in terms of their world so to speak, or, to change their world, as (cultural) differences in risk factors and prevalence is the case in many of those who deliberately harm (Hjelmeland & Knizek, in press). It would therefore themselves with little or no intent to die (e.g., be more fruitful, as well as more methodologically Hjelmeland et al., 2002). This can be done within sound, to now focus on qualitative research, and across cultural contexts with a cultural approach particularly, but not only, in cultural contexts where which helps us develop an understanding of the we have little or no knowledge about suicidal phenomenon of suicidal behaviour as well as of behaviour, for instance, in low and middle income individuals displaying suicidal ideation and/or countries outside the West, or, in minority groups in behaviour. Qualitative methodology is thus useful in high income countries. However, we also need both cultural and cross-cultural studies. Qualitative qualitative studies to follow up the thousands of cross-cultural/comparative studies are theory quantitative risk factor studies already conducted in generating or theory opening, in contrast to the the West (and elsewhere) to try and find out why or hypothetical-deductive methodology where the how, if indeed they are, connected to suicidal researchers only seek to verify already established behaviour (Hjelmeland & Knizek, 2010; Hjelmeland so-called “great-man” theories (Nerheim, 1995). & Knizek, in press). According to Nerheim, the emphasis of the Both in-depth studies in one cultural context comparative perspective opens up for a as well as comparisons between cultural contexts, differentiation at a level where the hypothetical- within or across nations, are important. The main deductive exploration used by the natural sciences point is to utilise methods properly suited for such veils our vision of differences and that these endeavours, namely qualitative methodologies. As therefore are reduced to a question of traits by the mentioned above, qualitative (comparative) studies data themselves. The point of comparison is are theory generating. However, it is also possible, or therefore to function constructively with a view to even important sometimes, to start with theoretical independent theory development. We can discover frameworks, if we make sure these frameworks are things concerning our own culture by looking at it in applicable in cultural studies. Theoretical challenges the light of other cultures, and vice versa. and opportunities is thus what are discussed next. Comparative qualitative studies of suicidal behaviour across cultural groups and contexts can Theoretical Challenges and Opportunities thus open up for new ways of looking at the data. It is, however, important to emphasize that Lack of theoretical frameworks is common in when we argue for the need to take a cultural suicidological research in general (Knizek & perspective into consideration in suicidological Hjelmeland, 2007) and we need to develop such research, we do not always expect there to be frameworks relevant for cultural studies of suicidal cultural differences. It is just as interesting and behaviour. At present, risk factor studies with little or important to focus on similarities (and also to no theoretical basis are in abundance (Hjelmeland & publish studies finding similarities in different Knizek, 2010). However, even if not explicitly stated, cultural contexts as further discussed below). As much of this research is based on the biomedical Mishara (2006) has pointed out: illness model (e.g., von Uexküll & Wesiack, 1988) Suicidology research tends to either ignore where, for instance, mental illness is considered cultural differences entirely or focus upon a central in suicidal behaviour. Often, mental disorders, specific culture without examining possible particularly mood disorders, are presented as the most commonalities across cultures. An important important risk factor of suicide and often a causal link challenge for future research is to explore and between the two is implied (e.g., Cavanagh et al., understand the frontier between universal 2003; Isacsson & Rich, 2003). However, this aspects of suicide and its cultural specificity. reductionist biomedical illness model fails to provide (p. 2) the necessary theoretical framework for studying the , multifactorial phenomenon (or rather phenomena) of suicidal behaviour (Hjelmeland &

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Knizek, in press; O’Connor & Sheehy, 2000). intention is to influence other(s); 3) “Emotional Taking the cultural perspective into consideration towards oneself”, where a lack of love for the complicates matters even further since there are individual’s self is central, for instance, because of huge problems with the validity of psychiatric low self-esteem; and, 4) “Regulative towards diagnoses across cultures (e.g., Fernando, 2003; oneself”, involving punishment of the self, as the Jadhav & Littlewood, 1994; Kleinman & Good, individual feels that s/he cannot live up to the 1985) as well as cross-cultural differences in the demands of the surroundings. Qvortrup’s theory was relationship between mental disorders and suicide developed in Denmark, has found some empirical (e.g., Chan et al., 2001; Phillips et al., 2002; support in Norway (Hjelmeland et al., 2002a), and Tousignant & Laliberté, 2007; Vijayakumar et al., results from a European multicentre study 2005; Yang et al., 2005; Zhang et al., 2004). Thus, (Hjelmeland et al., 2002b) can also be interpreted in we need other theoretical frameworks. keeping with Qvortrup’s theory, although other interpretations for some of the categories were also Communication theory possible in both studies. In these two studies, analysis of 14 variables describing intentions involved in a A fruitful alternative might be to study suicidal act resulted in a four-factor structure suicidal behaviour within the framework of reflecting Qvortrup’s theoretical categories. However, communication theory where suicidal acts are a similar study in Uganda resulted in a two-factor viewed as acts of communication (Fleischer, 2000; structure indicating differences across cultural Hammerlin & Enerstvedt, 1988; Hjelmeland et al., contexts (Hjelmeland et al., 2008). 2002a; Jack, 1992; Knizek & Hjelmeland, 2007; Knizek and Hjelmeland (2007) have built on Lester, 2001; Qvortrup, 1999). This is, for instance, some of the work mentioned above and developed a based on Watzlawick’s (1991) thesis that everything functional model of suicidal behaviour as a human being does is communication and will communication (MoSBaC) through a combination of influence others. Hence, there should be no problem Scandinavian theories within the framework of in considering suicidal behaviour as communicative communication theory and semiotics. This model is acts; people are indeed communicating something to functional in that it can be used to analyse both verbal someone by killing or harming themselves, and non-verbal data. It is particularly developed with something also Farberow and Shneidman (1961) a variety of qualitative data in mind, but the typology alluded to already 50 years ago. Suicidal behaviour of the model could also be suitable for quantitative is a phenomenon with a process character due to its approaches (Knizek & Hjelmeland, 2007). This model dialogical communicative nature. The act is the may be a good starting point for studying suicidal outcome of a range of earlier events and dialogues behaviour in different cultural contexts but will most that have lead to a decision to kill or harm oneself. likely need to be adjusted in different ways depending This, in turn, functions as a statement and is a upon cultural, as well as individual, differences contribution to previous dialogues with significant (cfr.Valsiner, 2003 and 2007 above). others (Hjelmeland et al., 2002a). This connects the individual with their context. Thus, communication theory is well suited as a framework to study suicidality in different cultural contexts since Other relevant theoretical frameworks communication, while universal, may have different There are also other relevant theoretical aspects/meanings in different settings (Hjelmeland frameworks that might be particularly well suited for & Knizek, in press; Hjelmeland et al., 2008). suicidological research with particular emphasis on Speech-act theory developed by Austin the cultural context. Examples are entrapment theory (1962) and Searle (1969) is an aspect of (Williams, 1997) and action theory (Michel & Valach, communication theory relevant for suicidal 2001). These will not be further elaborated here. behaviour (Fleischer, 2000). Speech-act theory arose However, it is important to note that when working because it was recognised that signs have a qualitatively, it is not always necessary to have a fundamental dialogical structure and thus cannot be theoretical framework to start with. On the contrary, understood apart from the context they are with some theoretical frameworks we may actually embedded within (Johansen & Larsen, 1994). lose the context sensitivity that is the hallmark of Qvortrup (1999) has developed this concept further qualitative methodology. Thus, it would therefore be on the background of pragmatic linguistics in better to build new theories through systematic and relationship to suicidal behaviour. He suggests four transparent analysis of the data, like, for instance, in possible categories of suicidal acts in accordance Grounded Theory (Glaser & Strauss, 1967; Mugisha with the act’s function: 1) “Emotional towards et al., in press a). This may be particularly relevant in others”, where a statement is made about the countries or cultural contexts where no suicidological emotional relationship between the suicidal research has been done before. Furthermore, our individual and the other(s) that the act is designated research group’s research in Ghana and Uganda has for; 2) “Regulative towards others”, where the revealed that religion and morality are extremely

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Suicidology Online 2010; 1:34-52. ISSN 2078-5488 central aspects in viewing suicidal behaviour collaboration with native researchers in order to avoid (Akotia et al., 2009; Kinyanda et al., 2009; Kizza et what De Leo (2002) has referred to as al., 2009; Knizek et al., 2009a; Knizek et al., 2009b; “’epidemiological safari tours’ in developing Mugisha et al., 2009) and relevant theories in those countries” (p. 373) and to avoid the risk of domains might be particularly important in countries introducing bias, retaining ethnocentric and culturally where religion and spirituality are important parts of invalid methods (Kohn & Bhui, 2007). It is important most of the populations’ everyday life (see, for to emphasise that such collaboration across borders is instance, Verhoef & Michel, 1997). a win-win situation for both sides as well as for the suicidological field itself; this is not development aid

in the traditional sense (it is important to emphasise Ethical and Political Challenges that since universities, at least in Norway, are not

allowed to conduct development aid in the traditional Ethical and political challenges are sense). By such collaboration low and middle income discussed under one main heading since it often is countries get the chance to develop a culture sensitive difficult to separate the two. For instance, political knowledge base for suicide preventive efforts, high challenges/issues often have ethical implications. income countries learn more about understanding of In advocating for the importance of having suicidal behaviour in different cultural contexts which a cultural perspective on suicidological research I is indeed relevant since many of them have large argue for the necessity to increase research in low communities of immigrants/refugees/asylum seekers and middle income countries since we still have from low income countries, and, this, in turn, relatively little research on suicidal behaviour from enhances the whole suicidological field since we all such countries. Such research involves numerous get a more nuanced understanding of what suicidal unique ethical challenges in addition to the behaviour is all about. However, there are challenges traditional ones faced in suicide research in general. in such an endeavour, some of which are discussed in First of all, ethical principles may vary between the following. ethnic/cultural groups, for instance, in terms of the If a country does not have the necessary emphasis put on individual versus collective rights competence to conduct studies on suicide, I would (Kelly & Feeney, 2007). Moreover, in some low suggest that high income countries have a moral and income countries, suicidal behaviour is still ethical obligation to contribute to educate researchers, considered criminal according to the nations’ laws. for instance, by admitting and/or funding PhD- In addition, suicide carries a lot of stigma, is even candidates from/in low income countries. This is, of more taboo than in the West, and persons struggling course, also dependent upon the interest of potential with suicidal ideation, have carried out a suicide supervisors. Interested faculty is, however, not attempt, and/or have lost someone to suicide face a enough, it is also necessary with institutionalised lot of prejudice, even from health care personnel commitments. That is, it helps if the (e.g., Akotia et al., 2010). Illiteracy levels are high, institution/university in a high income country at the making informed, written consent (a requirement highest level implements collaboration with emphasised by ethics committees in the West) universities in low and middle income countries as difficult (Mugisha et al., in press b). All these, and one of their objectives. Together with my colleague more, issues relating to participants in suicide Birthe Loa Knizek, I have for the last 10 years studies add to the common ethical challenges in supervised PhD-students from some African countries suicidological research. These issues are, however, in more or less official collaboration with universities dealt with in detail elsewhere (Kizza et al., in press; in these countries. We have frequently experienced at Mugisha et al., in press b). Here, only some of the our own university that it is somewhat looked down at ethical and political challenges resulting from lack to do that; it is considered more prestigious to of local competence and hence focussing on collaborate with reputable American universities. This researchers and the research process are discussed. might also be the case elsewhere. It should also be

mentioned that PhD-students from low income Collaboration between Researchers from High and countries may face difficulties at home when it Low Income Countries becomes known that they are studying suicidal

behaviour. They may find themselves ridiculed by Local mental health professionals in low colleagues who do not understand why they want to income countries who are interested in doing suicide study such an “awful” and taboo topic. research may find themselves dependent upon However, we maintain that high income researchers from high income countries, both countries, such as, for instance, Norway, have a moral because they may lack research competence and/or obligation to contribute to knowledge development in because they don’t have the necessary funding to low income countries. In our own research, we have conduct the research. On the other hand, for funded PhD-students in three different ways: 1) researchers in high income countries interested in through the quota programme at the university doing research in low or middle income countries it (money from the Norwegian Government to fund is important to conduct the research in close

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Masters and PhD-students from low income Cultures cannot meet, for ”culture” has no countries), 2) through research support from the agency. It is just a word, a concept, and Norwegian Research Council, and, 3) by making concepts do not meet. So talking as if cultures sure that regular PhD-positions are advertised in could do this or that – meet, collide, or clash – English so that also foreign students can apply (and begs the question of what drives people. It is of course, notifying collaborating people, not culture, who have the power to act. institutions/individuals in the South or East that such And it is people, not culture, who can change positions are open for applications). Also, a three- life for better or worse. (p. 83). year multicentre study with senior researcher participation from Ghana, Uganda and Norway has Collaboration as described above can perhaps been funded by the Norwegian Research Council. be initiated from both parties, but when one party Ideally, we can imagine collaboration holds the money, this party normally also can decide between researchers in high and low income the terms of the collaboration (see a discussion below countries as conducted on an equal basis of the double challenge researchers from low income (disregarded the fact that one party in some cases countries are facing). If the initiative comes from may be a PhD-student and the other the researchers in a high income country, although professor/supervisor); one party may hold the sometimes necessary, this can be problematic. For research methodological and/or the suicidological instance, coming from the outside (the West/high competence and the other party may hold the income countries) advocating for the necessity to do necessary local cultural competence. Both parties research on a topic that is not only stigmatised and are mutually dependent upon each other to be able to taboo but also criminalised by the country’s laws may conduct good quality cultural research. However, create problems and be met with some resistance. It is when one party also holds the money, this will also important to be aware that since priorities of inevitably influence the power balance in the preventive efforts and strategies in low income relationship. Moreover, the party possessing the countries to a large degree is ruled by donor money, money may also be from the country that previously this might in some quarters create a backlash against had colonised the other party’s country. However, to “imported” programmes (S. Ndyanabangi, Ministry of refer to this as cultural differences would be Health, Uganda, personal communication, 2003). reductionist or at least a constriction of viewpoint However, that is not my experience from Uganda (Berliner, 2001); this is about power, not culture. where we were welcomed from day one; both by a Berliner claims that it is a difference in distribution part of the professional mental health community as of power as a background for the two parties well as the Ministry of Health (although some meeting, and hence in the meeting. This creates negative attitudes from other parts of the mental ethical challenges one should be aware of. health community as well as people in high places at Moreover, in such collaborative projects the university could also be detected). We (accidently) people from two or more different cultural found a mental health professional (Eugene backgrounds (both in terms of what one traditionally Kinyanda) who, after listening to my lecture on thinks about as culture and also perhaps professional at the national psychiatric hospital, cultures as discussed above), with their own inherent expressed interest in studying suicidology, and, a individual culture(s) have to learn to communicate couple of years later, we had managed to secure with each other and that can be a challenge. For funding for his PhD-study at our university as a quota instance, my first PhD-student from an African student. He, in turn, introduced us to the Principal country was a black male psychiatrist (Eugene Medical Officer in charge of the Mental Health Kinyanda). He was then to be supervised by a white Department at the Ministry of Health, Dr. Sheila female ; a situation with a potential to Ndyanabangi. She was aware that suicidal behaviour challenge communication at many levels (for the was a serious public health problem in Uganda and record: it worked out well in the end and we are that action needed to be taken in order to deal with it, currently supervising new PhD-students from but they needed help from the outside in order to start different professions together). Berliner (2001) such work. She has given us moral support from that refers to this as the transcultural perspective; the day onwards (this was about 10 years ago). The process that emerges when people from different Ministry of Health in Uganda was also interested in cultural backgrounds meet and communicate with getting the law criminalising suicidal behaviour each other. In this interplay between cultures, some abolished and has asked the psychiatric community to sort of “over-cultural wholeness” is the result. It is establish dialogue with the Law Reform Council so important to be aware of this in the research process; that they can start to change attitudes with regard to it may indeed have implications for the analyses. If this. There is, however, some resistance in the there are problems in such a meeting between people juridical community since many of the lawyers from different cultural backgrounds, it is often believe that keeping suicidal behaviour criminalised is referred to as a “culture clash”. However, in the suicide preventive. It should perhaps be mentioned words of Wikan (2002): that in some of the countries where suicidal behaviour

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Suicidology Online 2010; 1:34-52. ISSN 2078-5488 still is criminalised by law, the law is a reminiscence weight than local or regional journals. This is also an of the old colonial government. ethical issue insofar as editors through these biases Our experience from Uganda was then to may actually be contributing to the prevailing start by finding interested professionals and then get inequities in global research (Sumathipala et al., in touch with the authorities and anchor our 2004). If research from low income countries cannot activities there. Other approaches may work better get published in well recognised journals, this, in turn, elsewhere. It is, however, important that the research affects the possibility of getting funding for such is anchored with the authorities in countries where research (Hjelmeland & Knizek, in press). Patel and suicidal behaviour is not only stigmatised but also Sumathipala (2001) argue that editors have a moral criminalised, both at the country governmental level duty to pay attention to the barriers researchers in low as well as at the various relevant local levels. This is income countries are facing and a moral obligation to necessary when approaching potential participants in publish studies from such countries. However, this the studies (discussed in depth in Kizza et al., in does not mean that the quality requirements should be press, and, Mugisha et al., in press a). In aiding the any lower than for Western papers since that “would process in “outsiders” advocating for the importance be at best patronising and at worst discriminatory” of doing research on suicidal behaviour in countries (Patel & Sumathipala, 2001, p. 409). Rather, a where it is still stigmatised and/or criminalised, the collaborative editorial style should be considered International Association for Suicide Prevention (Patel & Sumathipala, 2001; Vetter, 2003) to help (IASP) and the World Health Organisation (WHO), improve manuscripts, if the studies themselves are of for instance, may play important parts as gate- good quality. openers at the governmental level. This has been Sometimes good quality papers from non- suggested by suicide researchers in relevant Western countries finding similar things as have been countries and I suggest IASP take on this challenge found in the West are rejected by Western based and adopt a more active role here. journals because editors feel they do not contribute any new knowledge, thereby failing to recognise the Negative Attitudes to “Cultural” Research in some importance of finding both similarities and differences Western Based Journals in different cultural contexts (cfr. the quotation above by Mishara, 2006). This is similar to the heavily One political challenge is that editors of criticised publication bias resulting from only European and American based journals sometimes publishing studies where differences or effects are reject manuscripts, not because they are badly found and not publishing studies where no difference written or based on flawed studies, but because they or effects are found, for instance, in pharmaceutical contain a “cultural” perspective, here in the meaning research. The consequence is a missed opportunity to of studies conducted “elsewhere”, which is then enhance our understanding of suicidal behaviour in a deemed irrelevant for a Western audience. This has cultural context. been documented for psychiatric research in general However, some Western based journals by, for instance, Patel and Sumathipala (2001) and relevant for suicidological research do indeed Sumathipala et al. (2004) and also Alem and Kebede welcome research from cultural contexts outside the (2003) have pointed to the challenge of “lack of West. There are, of course, those with “cultural” in demand for (and social appreciation of) research the name, like, for instance, Transcultural Psychiatry from developing countries” (p. 185). Our and Cross-Cultural Psychology, but also some general multicultural suicidological research group, as well journals have a reputation for publishing “cultural” as other colleagues from low income countries, also studies, for instance, Acta Psychiatrica Scandinavica have numerous experiences with this. In rejection and British Journal of Psychiatry (Westermeyer, letters, editors in some Western based journals, both 2009). There are also many others. Of the general mental health journals as well as suicidological journals, Crisis clearly is conscious of suicidological ones, recommend submitting the its obligations in this respect being the official journal papers from, for instance, African countries to of the International Association for Suicide African or “regional” journals since the results are Prevention (De Leo, 2008). In the four-year period deemed more relevant for a local audience. Such an 2005-2008, 34% of the publications in Crisis came attitude not only contributes to impede the from Non-Western parts of the world (Hjelmeland & development of a valid evidence base to inform Knizek, in press). The percentages for Archives of practice regarding suicide preventive efforts in non- Suicide Research (ASR) and Suicide and Life- Western and/or multicultural (Western) contexts, but Threatening Behavior (SLTB) were only 16% and is also a hindrance to the advancement of 15%, respectively. However, only 15% of the studies suicidology itself since we need to have research published in Crisis, 12% in ASR and only 4% in SLTB from different cultural contexts in order to mentioned culture in some form in the title and/or in understand the phenomenon better. Moreover, what the abstract and thus reflected a specific cultural focus these editors seem to have forgotten is that their (Hjelmeland & Knizek, in press). journals are read all over the world and carry more

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Why the resistance in some journals towards current in psychiatry may take us in such a direction. including “cultural” perspectives? For instance, at the 2nd World Conference of the World Association of Cultural Psychiatry (in Norcia, Part of the problem might perhaps be the current Italy, September 2009) a leading cultural psychiatrist, very high emphasis on biological issues in in a comment to one of the plenary talks, reported that psychiatry in general and hence in suicidology in the new director of a psychiatry department in the particular. At present, psychiatry and behavioural USA recently had fired all the with the sciences are developing in a very biological argument that from now on they were only going to (genetic) direction (Brinkmann, 2009) and this, in do real psychiatry, and then it was not necessary to turn, has implications for suicidology. In some talk to people. That is a scary point of view in my circles, various kinds of biological approaches to opinion and perhaps we may head towards a similar suicidal behaviour thus are deemed the only real development in suicidology unless we take firm scientific approaches to explaining suicide. Thus, action to avoid it. Colleagues around the world report studies on hormones, genes and neurotransmitters that it is getting increasingly difficult to get funding are in demand, and various kinds of brain-imaging for research projects that do not at least have some techniques are developing fast. We can also see a biological component. This turn of events may be a “biologyfication” of the language in the field. For reason why it is so difficult to get cultural issues instance, “endophenotypes” seems to have become a accepted as important in some circles. With the new new fashion word for (some specific types of?) risk brain-imaging techniques psychiatry, and suicidology, factors. Endophenotypes are genetically induced may be heading towards (back to?) a very mechanistic biological markers; intermediate traits that lie view of human beings. A potential consequence of somewhere on the developmental pathway from finding biological markers for suicidal behaviour is genes to phenotype (Gottesman & Gould, 2003). that this makes it rather easy to think of medication as However, as Stuppia (2009) has emphasised, they the best/cheapest/easiest possible treatment; it may be are risk factors, not illness, and they need considered easier to treat a chemical imbalance with environmental influences in order to lead to illness. chemicals instead of spending a lot of resources on Stuppia talks about psychiatry, hence referring to the unveiling the reason(s) for this imbalance and whether illness concept, but we can easily replace illness it would be better for the patient to treat it with with behaviour here to make it relevant for alternative therapies. Due to the high cost of brain- suicidology. It is important to note that most of the imaging equipment it is not likely that culture specific phenotypes are not genetically conditioned, but MRI-studies will be conducted on a large scale, for culturally induced (Stuppia, 2009). The same instance, in low income countries, but it is far from genotype can result in very different phenotypes unthinkable that some, for instance, pharmaceutical depending on the cultural context (Kim, 2009). Such companies will generalise the effect of medicines information seems somehow to be lost in all the from one cultural context to another (it has been know focus on biology. Moreover, in a recent Crisis to happen) although there is evidence of culture (both editorial, Larkin and Beautrais (2010) describe the clinician’s as well as the patient’s) influencing the “suicide-related endophenotypes” (p. 2) and in so effect of drugs (Yu et al, 2007). This is, indeed also an doing refer to many of the commonly known risk ethical issue as well as a political one. factors, for instance, psychiatric illness, alcohol and However, there is no reason why biological substance abuse, old age, partner violence, criminal research should exclude or diminish the focus on behaviour, firearm ownership, etc. Thus, the use of cultural influences; on the contrary. As Chen and the concept endophenotypes seems to be getting a colleagues (2007) have pointed out: “Biology is not broader and broader definition. This ‘culture free’, findings derived from the field of “biologyfication” of (the language of) the biological psychiatry need to be understood in the suicidological field may contribute to take the context of culture and ethnicity to avoid misleading attention away from the importance of cultural and mis-interpretation” (p. 78). As mentioned above, issues; issues that are essential in the suicidal the same genotype can result in very different process. phenotypes depending on the cultural context (Kim, Moreover, brain-imaging is now promoted 2009). Henningsen & Kirmayer (2000) argue that: as an important contribution to suicide prevention. “increasing knowledge of neurobiological In the words of Mann (2005): “The clinician needs mechanisms does not indicate the triumph of to know which depressed patient is at risk for reductionist models in the sciences of the mind. On suicide, and one promising direction is to begin the contrary, recent trends in using brain imaging to measure the predisposition to underscore the significance of social context …” (p. suicidal behaviour …” (p. 102). In other words, it 468). The genetics involved in mental disorders may no longer be necessary to talk to people in order related to suicidal behaviour vary significantly across to find out whether they are suicidal; we can just ethnic groups (Chen et al., 2007; Yu et al., 2007). take pictures of their brains. This may not be what And, in the words of Markus and Hamedani (2007): Mann actually means, but the strong biological “… before looking for … the genetic underpinnings

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Suicidology Online 2010; 1:34-52. ISSN 2078-5488 of a given behaviour, it would seem wise, and also Culture is indeed influencing psychiatric (and hence scientifically sound, to determine whether a given suicidological) research itself (Chen et al., 2007) and observed behaviour can still be observed once the biomedicine and psychiatry are culturally constructed context shifts” (p. 29). bodies of knowledge (Kirmayer, 2007). What editors Transcultural has shown that rejecting papers from non-Western parts of the world cultural background can influence neural activity may have forgotten, apart from the fact that all (Stompe, 2009) and research in neuroplasticity has Western societies are multicultural, is that all demonstrated that it seems to be few limits to what research, behaviour, and treatment takes place in a the brain can do and develop into with different specific cultural context that actually consists of many environmental stimulations and that biological specific cultural contexts simultaneously. The patterns in the brain both can be created and problem is perhaps that one does not see one’s own changed by experience (e.g., Badenoch, 2008; cultural context because one looks at it as something Doidge, 2007; Mogensen, 2007; Schwartz & natural: “Like fish in the water we fail to ‘see’ culture Begley, 2002). And, since experiences occur in because it is the medium within which we exist” particular cultural contexts, it should be self-evident (Cole, 1996, p. 8). why cultural aspects then are important to take into Above, the futility of the biomedical illness consideration in the analysis of the data, even model was outlined. Most suicide researchers today biological data. Moreover, in terms of suicide would probably agree that this model is too simplistic research and prevention it would perhaps be more and reductionist and not really a comprehensive fruitful to focus more on peoples’ experiences in enough approach to study suicidal behaviour. It is different cultural contexts and less on their probably not considered politically correct to neurobiological structures that might even be there explicitly promote the biomedical illness model as an in the first place because of some experiences. After appropriate framework for suicidological research. all, “… biological beings become human beings However, the current increasing emphasis and through their engagement with the meanings and prioritising of biological research somewhat practices of their social world …” (Markus & contradicts this and there seems to be a gap between Hamedani, 2007, p. 32). People are complicated, politics and reality here that perhaps should be reflective creatures and because of “… its symbolic brought attention to. basis, the flow of human conscious experience … is not reducible to any finite set of bio-physical Negative Attitudes towards Qualitative Methodology causes” (Pickering & Skinner, 1990, p. 2), and, still according to Pickering and Skinner (1990): Above it is argued that it is important to start The mind-brain system that supports human with cultural research before it gives meaning to do consciousness is … a uniquely complex mix cross-cultural research, and, that it is necessary to start of physical, biological and socio-cultural with qualitative methodology in cultural contexts systems, integrated within an historical where little or no research has been conducted before process. The flow of experience generated by in order to get an understanding of what suicidal the interplay of causes and effects within this behaviour means in different cultural contexts. There process will be correspondingly complex. is, however, no doubt that there is resistance towards Describing this flow will require more than qualitative research methodology in much of the just a combination of terms from the natural leading power structures of the scientific community sciences ... . (p. 2) represented by funding sources, journal editors and reviewers (Brinkmann, 2009; Hjelmeland, in press; In other words, it is absolutely essential to Hjelmeland & Knizek, 2010; Hjelmeland & Knizek, take the cultural perspectives into consideration in in press, Lincoln, 2010; Marchel & Owens, 2007). all suicidological research, including the biological Some might perhaps object to referring to this as a one. However, the current biological turn of events political challenge; in some circles there is still a in both psychiatry and suicidology gains momentum strong belief that qualitative methodology is simply from the old, but persistent fight about what real about subjective opinions that have very little to do science is and strong forces are still pointing to with science. In this day and age, it is, however, fair natural sciences as the only real sciences capable of to say that such an attitude is, at best, based on providing the answers we need. Thus, with the focus ignorance about what qualitative methodology is, and on biological and genetic explanations of human the arguments used for rejecting qualitative studies behaviour on the increase, the focus on cultural may thus be described as more political explanations is decreasing (Brinkmann, 2009). In (prejudiced/narrow-minded) than scientific. This is psychiatry, this is an uphill battle (Alarcón, 2009), thus one of the most important challenges faced in which makes it so in suicidology as well. It is suicidology now in the beginning of the 21st century; therefore necessary to persistently advocate for the indeed an uphill battle. Qualitative methodology is, importance of the cultural context of suicidal however, crucial in order to deepen our understanding behaviour, research, treatment as well as prevention. of what suicidal behaviour means to people in

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Suicidology Online 2010; 1:34-52. ISSN 2078-5488 different cultural contexts (Hjelmeland & Knizek, Western context. Otherwise, researchers from low- 2010; Hjelmeland & Knizek, in press). income countries will continue to face this double The resistance towards accepting challenge; first they have to argue for the value and qualitative research might constitute a double relevance of their research also for a Western challenge for researchers in low income countries; audience, and if they then also use a methodology that not only are they met with resistance abroad from is not fully accepted in the West (or by influential editors, but also at home they risk being ridiculed by people everywhere), it is even more difficult for them colleagues. In an editorial of the British Journal of to get their work accepted in Western based journals Psychiatry, Doku and Mallet (2003) pointed out (or regional journals with editors educated in and/or that: influenced by the prevailing view in the West). Researchers in low-income countries are often under implicit or explicit pressure to conform Fernando (2003) claimed that: to Western models in exchange for Changing the culture of research so that it is collaborative arrangements, acceptance by the bottom-up (i.e. starts with user views and needs international scientific community, identified by people who suffer mental health participation in meetings and publications, problems) is likely to threaten vested interests and financial support. The lack of resources of the psychiatric establishment and so requires and the threat of intellectual isolation may a political will to enforce. (p. 205) push bright young researchers in these regions into adopting values, conceptual In other words, this is about politics and frames of reference and research agendas that power, and the question is, what can we do to change make their work acceptable to Western this? Some efforts have been made during the last colleagues. (p. 188) couple of decades to educate the opposition about the ignorance they show in their resistance towards They also refer to Jablensky (1999) saying qualitative research. For instance, Kvale already in that: “When this occurs, research questions and 1994 published the paper “Ten standard objections to findings that are thought to be at variance with the qualitative research interviews” where he elegantly dominant paradigm represented by scientific refuted all of them as invalid. He even pointed out journals and conferences tend to be put aside” (p. that they should already be outdated. Now, 16 years 188). later they still frequently appear in reviews and The resistance towards qualitative rejection letters (Hjelmeland & Knizek, in press). methodology also has ethical implications, especially in terms of suicidological research from a cultural perspective. Above, it was argued on Competence seen as a Threat rather than a Resource methodological grounds for the necessity to start in Low Income Countries with qualitative studies in countries/cultural contexts where little or no research has been conducted If you have managed to get a PhD abroad and come before. There are also some ethical arguments for home to your country as one of the first, if not the first this. Qualitative studies develop “understandings of psychologist or psychiatrist in the country holding a the phenomena under study, based as much as PhD, eager to utilise the competence gained, you may possible on the perspective of those being studied” be disappointed. In a country where people in (Elliott et al., 1999, p. 216). Qualitative interviews powerful positions, for instance, deans or heads of involve a voluntary conversation between the departments, do not themselves hold a PhD, you may interviewer and the interviewee adjusted to the be perceived as a threat rather than a resource. A interviewees’ needs/possibilities/wishes to express junior with a PhD may perhaps turn the power themselves and forward their own view on the issues hierarchy upside down and may thus find him/herself being discussed. It can therefore be argued that unacceptable in any of the relevant departments in qualitative studies are more ethical in certain their home country where their skills may be urgently contexts since they are more open/adjusted to the needed. They may have to settle for employment needs of the participants compared to quantitative elsewhere with few opportunities to continue the studies where normally predetermined, standardised research they trained for. That is a waste of and fixed-order questions, adjusted to the researcher’s needs, are asked. This may be competence, and all because some people in powerful particularly important in countries where suicidal places feel threatened by that very competence they behaviour is especially taboo, stigmatised, or even instead should see the value of and use. Perhaps post criminalised. There it is important to understand why doc grants funded from high income countries to and how it is taboo, for instance, and here qualitative researchers from low income countries with PhDs studies are essential. acquired from abroad, may contribute to ease their Thus, it will definitely help if qualitative reintegration back into the relevant institutions in their methods become more accepted as important in a home countries.

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Other (Financial) Challenges for both readers and authors, like for instance, this journal, Suicidology Online. In such journals the Another challenge is “piggybacking”, that quality of the paper, not the size of the authors’ is, in order to get funding for research on suicidal wallet, decides what is published when. behaviour, it has to be hooked up to research topics presently popular among funding institutions. A Concluding remarks relevant example for African countries is research on HIV/AIDS that is, relatively speaking, easy to More than 20 years ago, Boldt (1988) stated fund. In order to be able to do research on suicidal that “in order to develop valid social scientific behaviour at all then (a topic that is not easy to fund, theories of cause, suicidologists must make a partly because mental health is not a prioritised area paradigmatic shift from the prevailing universal, in low income countries), it is appended to a project invariant definition of suicide to systematic research proposal on HIV/AIDS. In addition it seems to into culture-specific meanings of suicide” (page 106). become increasingly necessary to at least have a This is also in accordance with the view of one of biological component in the project proposal on suicidology’s most important “founding fathers” suicide research to make it more edible for some Edwin Shneidman. In his definition of suicide he funders. In this way, funding sources contribute to emphasised the cultural importance by stating that steer the research in specific directions and thereby ”Currently in the Western world, suicide is a limit the possibilities of free sucidological research conscious act of ...” (Shneidman, 1985, p. 203, my directed by a country’s needs and requirements for italicising). In other words, the potential importance specific knowledge. of a focus on cultural perspectives in suicide research Above, it was outlined that some mental has been pointed out relatively long ago. Still, health professionals may get the opportunity to however, most of the suicidological research is carried acquire a PhD degree in a high income country by out in the so-called Western part of the world and different sources of funding. A political challenge most of it lacks a specific focus on cultural factors related to finances is that many of them prefer to (Hjelmeland & Knizek, in press). Moreover, many, stay on in the high income country after they have (particularly Western?) researchers seem oblivious as completed their PhDs, or even basic medical or to whether their results can or cannot be generalised psychological education, because they have a better to other parts of the world. For instance, a review of chance of creating a good life for themselves and the publications in the three main international their families there than in their home countries suicidological journals in the four-year period 2005- (something that is not difficult to understand). For 2008 revealed that 74% of the non-Western studies instance, Doku and Malet (2003) point out that there mentioned the region/country of the study in the title, are more Ghanaian psychiatrists in Canada than compared to only 22% of the studies from the West there are in Ghana; indeed a political challenge (75% vs. 55% in Crisis, 76% vs. 20% in Suicide and (brain-drain). Life-Threatening Behavior, 74% vs. 12% in Archives So-called ”open access” publication is of Suicide Research; Hjelmeland & Knizek, in press). another political challenge connected to funding. Mentioning the place where the study was conducted The main intent behind open access publication is in the title may, at least to some extent, be an that the publications should be available to everyone indication of whether the authors are conscious of the free of charge, indeed a noble intent. However, even fact that all studies are conducted within a specific though such publications may be open to all readers, cultural context and thus that there are potential they are not accessible for all authors. Open access limitations to generalising the results to other publication normally costs 2000-3000 USD for the contexts. If so, this level of consciousness seems to be authors, which means that authors from rich higher among researchers outside the West. However, countries/universities/research institutions are it is, of course, not possible to know whether the favoured. This development is then yet another decision to include the place of study was taken by the hindrance for researchers from low and middle researchers themselves or the journal editors. Perhaps income countries to get their publications out. Some the editors insisted that non-Western studies mention journals offer both opportunities, either open access the place of study already in the title to indicate that publication funded by authors published online the results may not be generalisable to Western immediately after acceptance, or, traditional contexts? It would be interesting to know. publication in the paper version of the journal and/or Many of us need to become more conscious by journal subscription online. The main problem of the cultural complexities and take the necessary with this is that in many journals today, the precautions in interpreting and generalising our submission rate is so high that it sometimes takes research results; researchers as well as clinicians and more than a year from acceptance to publication in others working with suicide prevention regardless of the paper version of journals. Thus, those who can profession need to develop a cultural competence. pay get their publications out first. Hopefully, more However, Kirmayer (2009) emphasises that not only and more journals will become truly open for access do we need cultural competence; we also need

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Suicidology Online 2010; 1:34-52. ISSN 2078-5488 cultural humility. When planning suicide prevention Akotia, C. S., Knizek, B. L., & Hjelmeland, H. (2010, programs in low income countries, it is also April). Attitudes towards suicidal people important to keep in mind that, for instance, Africa among nurses in Ghana. Impressions from a in general has only 0.34 mental health professional qualitative interview study with deliberate self- per 100 000 population (Vijayakumar, 2004). A harm patients. Paper presented at the typical Western suicide prevention program with a Workshop on attitudes towards suicidal high emphasis on suicide prevention in the mental behaviour, Department of Psychology, health care with education of, for instance, University of Ghana, Legon. psychiatrists and psychologists in how to assess and Alarcón, R. (2009, September). Diagnosis in cultural treat patients with mental illness and suicide risk as psychiatry. Round Table presentation at The one of its main objectives may not be particularly second World Congress of Cultural Psychiatry: useful in, for instance, an African country. Cultural Brain and Living Societies, Norcia, In light of the problems inherent in the Italy. concept of culture discussed above, as well as the Alarcón, R. D., Bell, C. C., Kirmayer, J., Lin, KM, development towards an increasing Westernization Ustun, B., & Wisner, K. L. (2002). Beyond the of the non-Western parts of the world and an funhouse mirror: research agenda on culture increasing multiculturalization of the Western world, and psychiatric diagnosis. In: D. J. Kupfer, M. resulting in a rapid hybridization of cultures, it can B. First, D. A. Regier (Eds.), A Research be argued that it might be better to abandon the Agenda for DSM-V (pp. 219-281). Washington concept of culture altogether and instead simply talk DC: American Psychiatric Association. about context (B.L. Knizek, personal Alem, A., & Kebede, D. (2003). Conducting communication, 2009). That is, however, another psychiatric research in the developing world: discussion. But whether we call it culture or just challenges and rewards. British Journal of context; in suicide research and prevention it is still Psychiatry, 182, 185-187. important to focus on human beings in their contexts Austin, J. L. (1962). How to do things with Words. instead of just focussing on parts of human beings in Oxford: Oxford University Press. isolation. In the words of Eisenberg (1986; in Lewis- Badenoch, B. (2008). Being a brain-wise therapist. A Fernandez & Kleinman, 1995): “Psychiatry can no practical guide to interpersonal neurobiology. more afford to be contextless than it can afford to be New York: W. W. Norton & Company. mindless or brainless” (p. 444), “psychiatry” can Berliner, P. (2001). Transkulturel psykologi. Fra easily be replaced by “suicidology”. tværkulturel psykologi til community psykologi. [Transcultural psychology. From Acknowledgements cross-cultural psychology to ]. Psyke & Logos, 22, 91-112. I am extremely grateful to our fantastic Ghanaian- Bhugra, D., & Bhui, K. (2007). Preface. In: D. Bhugra Ugandan-Norwegian research group in the project & K. Bhui (Eds.), Textbook of Cultural “Suicidal behaviour in a cultural context” for all the Psychiatry (pp. xvii-xviii). Cambridge: valuable, interesting and vivid discussions we have Cambridge University Press. had over the years; always with a lot of humour and Boldt, M. (1988). The meaning of suicide: laughter in spite of strong differences of opinion Implications of research. Crisis, 9, 93-108. from time to time. These discussions have Brinkmann, S. (2009). Mellem synapser og samfund. contributed to the content of this essay in many [Between synapses and societies]. Århus: different ways, so thank you very much Charity Aarhus universitetsforlag. Akotia (Ghana), Eugene Kinyanda (Uganda), Birthe Cavanagh, J. T. O., Carson, A. J., Sharpe, M., & Loa Knizek (Norway), Dorothy Kizza (Uganda), Lawrie, S. M. (2003). Psychological James Mugisha (Uganda) and Joseph Osafo studies of suicide: a systematic review. (Ghana). Each and every one of you has taught me a Psychological Medicine, 33, 395-405. lot! I am particularly grateful to Birthe Loa Knizek Chan, K. P. M., Hung, S. F., & YIP, P. S. F. (2001). for constructive comments to the manuscript. Suicide in response to changing societies. Child and Adolescent Psychiatric Clinics of North References America, 10(4), 777-795. Chen, C.-H., Liu, S.-K., & Lin, K.-M. (2007). Akotia, C. S., Hjelmeland, H., Kinyanda, E., & Culture, ethnicity and biological psychiatry. In: Knizek, B. L. (2009, October). Experiences of D. Bhugra, & K. Bhui (Eds.), Textbook of DSH-patients in Ghana: The role of religion Cultural Psychiatry (pp. 72-80). Cambridge, and spirituality. Paper presented at the XXV Massachusetts: Cambridge University Press. World Congress on Suicide Prevention of the Cohen, D. (2007). Methods in cultural Psychology. International Association for Suicide In: S. Kitayama & D. Cohen (Eds.), Handbook Prevention: Suicide Prevention in Different of Cultural Psychology (pp.196-236). New Cultures, Montevideo, Uruguay. York: The Guilford Press.

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